Co-Pay Assistance 101
Christina Bach, MBE, MSW, LCSW, OSW-C
The Abramson Cancer Center
Last Modified: December 13, 2012
What is co-pay assistance?
Co-pay assistance is financial assistance for co-pays for patients WITH insurance - but whom we would consider to be UNDERINSURED (commercial/private/Medicare).
Underinsured means that the patient has out of pocket costs, which are not covered by the medical insurance plan, which can impact financial well-being and access to care. When investigating your potential out of pocket responsibilities for care you want to know:
- What is my deductible?
- What is my out of pocket maximum? Is this an annual amount? (i.e does it reset every year and if so, when-January (calendar year), July (fiscal year), or another anniversary date predetermined by the plan.
- What percentage is paid by my insurance plan?
- What will this treatment cost me?
Both the insurance company and the insurance verifier/pre-cert coordinator/financial counselor at your treatment site should be able to get you the answers to these questions. Once you have ascertained that you have out of pocket responsibilities related to your treatment, it is time to investigate if you are eligible for co-pay assistance.
I advise patients/support persons to keep a notebook/folder with a section dedicated to financials, bills and costs. ALWAYS keep track of whom you speak with at your treatment site, the insurance company or any Co-pay assistance foundation.
What co-pay assistance is available?
There are many private foundations that are funded by both pharmaceutical companies and other private donors to provide assistance with co-pays and out of pocket medical expenses. Each of these foundations has specific diagnostic and financial need criteria a patient must meet to be eligible for financial assistance. They also dictate what kind of treatments are covered for each disease (i.e. they don’t fund experimental treatments), as well as how health care organizations can bill for services to the foundation or if the patient can be reimbursed for costs. Some co-pay assistance foundations will cover the cost of office visits co-pays ONLY IF the patient is receiving treatment on the same day. Some funds for specific diseases can also assist with insurance premium payments. It is important to familiarize yourself with the guidelines and regulations of EACH foundation you receive assistance from, and yes, you can receive assistance from more than one source.
In cancer treatment, the following organizations provide co-pay assistance:
- Cancer Care Copay Foundation
- The Leukemia and Lymphoma Society Co-Pay Assistance Program
- Patient Advocate Foundation Co-Pay Relief Program
- The Chronic Disease Fund
- The Healthwell Foundation
- Patient Services Incorporated
- National Association for Rare Disease (NORD)
- Patient Access Network Foundation
- Johnson and Johnson Patient Assistance Foundation
Each of these organizations provides assistance to various diagnoses and for various drugs. Their funding seems to change REGULARLY, so it is important to check EACH website for EACH foundation regularly regarding YOUR diagnosis and if funding is available.
Here are some KEY points to know about co-pay assistance:
- Patients must meet BOTH diagnostic & financial criteria.
- Co-pay assistance covers costs of medication (oral and IV); some co-pay foundations also cover insurance premiums. Co-pay assistance DOES NOT cover costs of nursing, pre-medications or administration of the medication.
- Co-pay assistance typically does not cover co-pays for diagnostic imaging, labs, radiation, travel, lodging or office visits.
- For programs that do cover office visit co-pays (LLS and Cancer Care), office visits CAN be covered under Co-Pay assistance ONLY if the patient is receiving chemotherapy on the SAME DAY.
- Co-pay assistance DOES NOT apply to the uninsured.
- Co-pay assistance (private foundations) differs from co-pay cards (drug company sponsored).
- Co-pay assistance DOES NOT apply to treatments that are DENIED by the insurance company.
- Co-pay assistance DOES NOT cover experimental, non-approved treatments.
Is there financial criteria I must meet to qualify for assistance?
Each co-pay foundation sets its own income requirements to receive assistance. The Leukemia and Lymphoma Society’s is that a patient qualifies if they are within 500% of the poverty level - for a single person they are permitted to have an income of around $54000. This amount adjusts for the number of persons in the household.
Cancer Care applies a financial eligibility at 400% of the poverty level. For a single person, that translates to $44,680 per year.
It is important to gather your financial information when applying for co-pay assistance including tax returns, pay stubs, and social security award letters. These foundations do not tend to ask about other financial assets in their eligibility determination process. They should never ask about your home value or cars. These foundations WILL take into account outstanding medical bills (as debt) and may adjust income accordingly.
For more information about the specific financial guidelines for co-pay assistance, contact the individual foundations directly.
What is a co-pay card?
The co-pay card appeared in 2005 as a means by which pharmaceutical providers could, by offering instant rebates to patients, combat some of their challenges to prescription pharmaceuticals, including generic competition & lack of patient compliance and persistency due to out of pocket cost for the medication at the commercial pharmacy
Co-pay cards are ONLY for patients who have private/commercial insurance; they do not apply for patients with Medicare Part D sponsored RX plans or Medicaid.
Co-pay cards can be very helpful for certain medications including:
- Avastin (Genentech)
- Rituxan (Genentech)
- Neulasta (Amgen)
- Xgeva (Amgen)
- Zometa (Novartis)
- Herceptin (Genentech)
- Gleevac (Novartis)
- Tarceva (Genentech)
- Oxycontin (Purdue)
Where can I get help with co-pay assistance?
Your oncology social worker or navigator should be able to help you with the process of determining what programs you may be eligible for as well as helping with applications and facilitating medical information getting to the foundation in a timely fashion. It is important to communicate with your cancer care team about the costs of your care and how this may impact your ability to participate in your treatment plan. There is a great deal of assistance out there to help cope with the financial burden of cancer treatment. Be sure to advocate for yourself and talk to your social worker!